The Internet of Healthy Things Redux: Chapter 5, The New White Coat Anxiety*

*Thanks to Tara Menon and Gina Cella for their help in editing this piece

This year, I have been blogging about the 10th anniversary of my first book, The Internet of Healthy Things (IoHT). While taking a trip down memory lane, it has been fun to: 

• Assess how well my coauthors and I did in predicting the future.

• Wonder what people we interviewed are doing now. 

• Recall the companies we highlighted and ponder where they are today.

This motivated me to commit to posting about a different chapter regularly throughout the year and to ask you, my valued readers, to grade us.

If you haven’t had a chance to read the first four installments, you may do so here (but go ahead and finish this one first!).

Chapter 5 is a mix of thoughts about the various pressures healthcare providers face in the early 21^st century, typical attributes of physicians, and why these phenomena (the pressures and the attributes) make it challenging to sell innovations to physicians. While there are some predictions that I will assess, most of the chapter is still current. This chapter, in fact, could be part of a 2025 version of the same book. This sheds light on why the transition from primarily face-to-face interactions with patients to a multichannel, connected health world has been so slow, while other industries have advanced during the same period.

The chapter meanders a bit, but in the end, it ties together a few concepts in a logical argument for why doctors had been so reluctant to adopt connected health as part of their practice circa 2015. The thread goes something like this: doctors are busy, burned out, and thus have little time for “one more new thing” to change practice patterns, even if it makes sense from a quality-of-care perspective. They are often overconfident and have outsized influence in health system decision-making processes. As of the book’s writing, physicians had minimal teaching in medical school about any of the digital health tools. 

Other issues covered briefly in this chapter include how EHRs are both a blessing and a curse, and particularly how they do not offer a willing receptacle for connected health data (too many normal readings from monitoring compared to culling out readings that would be of value in decision making). There is also a discussion about physician bias toward face-to-face, in-person encounters being more effective than virtual ones. 

From there, we tell the story of a clinical trial conducted at the innovation group I led at Partners HealthCare (now Mass General Brigham), the Center for Connected Health, which tested an early AI forerunner (a relational agent called Karen, the virtual coach). The results showed that individuals who had daily interactions with Karen were more adherent to their walking routine than those who did not. We mentioned this to make the point that sometimes engaging with a machine is compelling and may even be more effective than human contact in certain situations. 

So, as I read it over, I decided to touch on these various topics and compare the state of affairs in 2025. In some cases, we’ve made positive progress, but in others, there has been no movement. The net effect is that providers are still skeptical of digital health applications – perhaps less so than in 2015, but we are still in the early adoption phase, much earlier than we predicted we’d be by now.  

Ten years later…

Burnout

This one needs little additional ink. Physicians are still more dissatisfied than not, and many are still leaving the profession. I didn’t bother to look up the statistics because I find the whole thing so depressing. The reason we led with this concept is that it was a barrier to digital health adoption ten years ago, and while that may be slightly less so, it is still the case in my experience for many. One possible bright spot is the use of ambient scribes, a speech-to-text and generative AI combination that listens to conversations between doctors and patients, generating a draft progress note. The adoption of this tool has been impressive.

I remain skeptical of its long-term utility, but I hope to be proven wrong. In any case, the electronic health record remains a lightning rod of controversy regarding the quality of care versus burnout. I grew up in an era where some doctors kept office records on 4” X 6″ index cards, so I appreciate having all of the patient’s information at my fingertips. Other than that, I’ll leave this as a topic for a future blog post.

Physicians as Decision Makers

This has also not changed. Like it or not, healthcare organizations rely on physician opinions for many decisions, including evaluations of new technologies. The concept of “do no harm” creates a risk aversion that, while seemingly healthy for consumers and patients, hinders the adoption of innovations. Just look around at all of the other service-provider industries you interact with. You’ll quickly see how far ahead they are on digital engagement and integration, in contrast to your doctor or healthcare delivery system.

Adoption of Digital Health Tools

This is a mixed bag.  

Most credit the pandemic experience with advancing the concept of virtual visits. So far, there has been fair, sustained reimbursement for these visits, and they persist in 2025 as an integrated part of most care delivery models. So, a victory here.  

Likewise, reimbursement for remote patient monitoring (RPM) has correlated with increased adoption of that modality. I would say we’re still underperforming in that area compared to the predictions we made in 2015, and a significant part of our vision for RPM adoption – specifically, increases in value-based payment arrangements – has not come to pass. We still have a long way to go to realize the vision of one-to-many care that RPM allows for.

On a side note, I have to say how amused I was to be reminded of the story of Karen, the virtual coach. It seems so quaint now, as more and more people are using generative AI to create imaginary loved ones and mental health therapy chatbots. As a society, we have more than proven that sometimes interactions with machines can be fulfilling. The discussion nowadays is whether we’ve already gone too far in that regard and what the future holds.

Medical School Curriculum

In preparation for this post, I asked several medical students and trainees how much teaching they get on digital health-related topics in medical school. Taking AI out of the mix (it is such a hot topic, everyone is grappling with it these days), the answers were mixed. Suffice it to say that there is no standard, uniform curriculum for digital health as you’d find for, say, anatomy. We have a way to go there.

The last part of the chapter is a series of recommendations for those trying to sell new tech to physician decision makers:

• Communicate with respect and deference

• Provide solid evidence and data

• Be persistent through long sales cycles

• Demonstrate clear benefits: improved patient care, enhanced reputation, financial advantages, or reduced workload

• Keep presentations brief and focused

  
  

I’d say this is still good advice.

Reflecting on this chapter was harder for me than the others so far. That is partly due to the seemingly disparate topics covered and partly because the adoption of innovations discussed is very hit or miss, seeming almost random. It’s interesting to think that, while we’ve solved some of the challenges causing anxiety for our “white coats” (and others still have a long way to go) new barriers are in place – like policy and regulatory hurdles – that continue to vex the permanent adoption of telehealth in care delivery.

What are your thoughts?